Grief, loss and dying
A patient states "I am okay with dying now." This is an example of what stage of grief?
Acceptance
What is the most effective way to prevent the spread of pathogens?
Hand hygiene
What population is at the highest risk for falls?
Older adults
A patient states they have pain in their abdomen but the nurse does not assess the abdomen. The patient then suffers negative consequences as a result. This is an example of what negligent act?
What is the first thing a nurse should do when they realize a medication error has been made?
Assess the patient
Crackles in the lungs, edema, and altered mental status are associated with fluid volume balance?
Fluid volume excess
Common symptoms of UTI seen in older adults
Confusion and decreased body temperature
List 3 assessment findings seen with poor oxygenation and perfusion
Tachypnea or bradypnea, restless, disoriented, cap refill > 3 sec, cyanosis, urine output < 30 mL/hr, weak pulses, shortness of breath, hyper/hypoventilation, accessory muscle use, tripod position, low oxygen saturation
Pressure injury with partial-thickness tissue loss and shallow open ulcer or intact blister
Stage II
A drop in blood pressure when changing positions
Orthostatic hypotension
Minimum timeframe of pain to be considered chronic
Greater than 3 months
Type of anesthesia causing CNS depression
General anesthesia
A patient states "This can't be happening to me, they've made a mistake." this is an example of what stage of grief?
A gown, gloves and cleaning with bleach is what transmission-based precaution?
Enteric precautions
What parts of a physical assessment are included with restraints?
What is the definition of the ethical principle Justice?
Providing equal care to all
What are the 3 checks of medication administration?
Compare HCPs order to MAR
Compare medication to MAR
At bedside, check medication against MAR
List 3 causes of hyperkalemia
Metabolic acidosis
Tissue catabolism
Renal disease
Medications: ACEI, ARBs, heparin, K+-sparing diuretics, NSAIDs, potassium chloride
List 3 components of patient teaching for healthy bowel elimination
Drink 2-3 L of fluid, exercise/increase movement, high fiber diet, going when you feel the urge to go
What is the best position(s) for a client in respiratory distress?
Tripod, high fowler's
Diet for wound healing
High protein, high fluid, high calorie, vitamins A, C and zinc
Incomplete lung expansion causing alveolar/lung collapse
Atelectasis
Pain that is poorly localized, in the organs, and commonly associated with disease
Visceral pain
Postoperative complication causing redness, swelling heat and pain of the calf
Deep vein thrombosis
What does the skin look like when a patient is dying?
Mottling
Which stage of infection has infection-specific signs and symptoms?
Full stage of illness
Name 3 safety measures for a preschooler.
-Ensure child is wearing proper safety equipment and teach its importance
-Teach about fire and water safety
-Never leave child alone/unsupervised (esp. near water)
-Ensure the child is always in a safe environment
- Practice safety and emergency procedures
-Making sure guns/weapons are properly stored and out of reach from child
-Making sure chemical are properly stored
Doing no harm and not inflicting unintentional or intentional harm to patients is an example of what ethical principle?
Nonmaleficence
What kinds of medications cannot be crushed?
Extended release and enteric coated
pH 7.32 (normal 7.35-7.45)
PaCO2: 55 mmHg (normal 35-45 mmHg)
HCO3: 33 mEq/L (normal 22-26 mEq/L)
Partially compensated respiratory acidosis
What are 3 ways to prevent incontinent-associated dermatitis?
Perineal skin cleansers, barrier cream, non-invasive urinary devices, use of nonocclusive absorbent products
List 3 factors that affect oxygenation and perfusion in older adults
Decreased airway elasticity
Decreased muscle tone
Decrease chest compliance
A pressure injury that is non-blanchable maroon, intact or not intact, can be blood-filled blister
Unstageable
Effects of immobility on the urinary system
Urinary stasis, UTI, kidney stones
Type of interventions including techniques like guided imagery, heat/cold therapy, and repositioning to relieve pain
Non-pharmacological pain interventions
The process of pausing before anesthesia to confirm patient identity, procedure, procedure site, consent verification
Time out
What is the name of a person who is picked to make medical decisions for a patient in case they cannot respond?
Durable power of attorney
What are sources of hospital acquired infections?
Urinary catheters, surgical sites, central lines, ventilators
List three alternatives to restraints.
sitter, bed alarm, cool room and warm blankets, pillows, music, diversional activities, scheduled toileting, cover lines and tubes, move patient closer to nurse's station
Failure to note and report a critical change in a patient that leads to harm is an example of what element of malpractice?
Breach of duty
What are the parts of a medication order?
Patient's name with second identifier
Date and time prescription written
Name of drug
Dose of drug
Route to be administered
Frequency of administration
Start and stop time
Signature of prescriber
List 3 clinical manifestations of hypernatremia
Restlessness, disorientation, agitation, weakness, seizures, muscle cramps, edema (peripheral or pulmonary), hallucinations
What are normal assessment findings of a stoma?
Red/pink, moist, protrudes outwards from skin level, edges of stoma are secure against skin
List 3 things to teach a patient on home oxygen
No smoking with oxygen, keep oils, grease, alcohol away, keep 6 ft away from source of fire (stove, fireplace, candle), no electrical equipment near oxygen administration set, caution with gas and electric appliance, secure tank to ground, don't increase O2 amount without calling provider, have fire extinguisher in home, have smoke detectors in home
Proliferation phase
Electrolyte imbalance caused by immobility
Hypercalcemia
Method for sleep promotion that involves providing multiple types of care all at once
Cluster care
3 complications of hypothermia
Cardiac disturbances, poor wound healing, hemodynamic instability, clotting difficulty, shivering
What are indicators for a referral to hospice?
-Could potentially pass in 6 months
-Declining cognitive status
-Poor nutritional intake
-Advanced age
-Comorbidities
-Frequent hospital admissions for acute decompensation
What are the steps in the chain of infection?
Infectious agent --> reservoir --> portal of exit --> mode of transmission --> portal of entry --> susceptible host
What do you do if a patient begins to have a seizure?
Place on side, cushion head, put padded side rails up, loosen clothing, ensure suction and oxygen available, lower bed
Failure to act as patient advocate
List the 9 rights of medication administration
Right Patient
Right Medication
Right Dosage
Right Time
Right Route
Right Reason
Right Assessment Data
Right Documentation
Right Response
pH: 7.45 (normal 7.35-7.45)
PaCO2: 48 mmHg (normal 35-45 mmHg)
HCO3: 32 mEq/L (normal 22-26 mEq/L)
Compensated metabolic alkalosis
What is the definition of stress incontinence?
involuntary loss of urine related to increase in intra-abdominal pressure (coughing, laughing, sneezing), associated with weak pelvic floor muscles
List the flow ranges of nasal cannula, simple mask, non-rebreather mask, venturi mask, and bag valve mask.
Nasal cannula: 1-6 L/min
Simple mask: 6-10 L/min (5-8 L/min according to textbook)
Nonrebreather: 10-15 L/min
Venturi mask: 4-6 L/min
Bag valve mask: 15 L/min
How does moisture contribute to skin breakdown?
3 signs of activity intolerance
Increased HR and RR, decreased or increased BP, SOB, dyspnea, weakness, pallor, confusion, vertigo
Type of neurologic disorder causing excessive daytime sleepiness and overwhelming urge to sleep no matter what is going on
Narcolepsy
3 symptoms of latex allergy
Urticaria, rhinorrhea, bronchospasm, circulatory and respiratory collapse